Movement Disorders A Team Approach

Movement DisordersA Team ApproachAt West Virginia University we take a team approach to the diagnosis and treatment of Parkinson’s and other movement disorders. Specialists in neurology, neurosurgery, neuropsychiatry, and neuropsychology pool their knowledge and coordinate their efforts to ensure the most effective treatment for each patient. Among the treatment options is deep brain stimulation, which involves an implantable device that uses electrical impulses to control abnormal neuronal activity in the brain. Dr. Donald Whiting is one of the nation’s leading physicians in this ?eld.Left to right: Neuropsychiatrist John Young, neurologist Cathrin Buete?sch, neuropsychologist Michael Parsons, neurosurgeon Donald Whiting.

For more information, contact Dr. Cathrin Buete?sch via the MARS line —800-982-6277.

Special ArticleFactors Related to Women’s Decisions to Smoke During Their Pregnancies ............................................................. 244

Managing Editor/Advertising DirectorNancy L. Hill, Charleston

Scientific ArticlesOveruse-Related Vascular Injury of the Hand — Hypothenar Hammer Syndrome: A Case Report ....................... 250 Giant Aneurysm of the Saphenous Vein Graft Presenting as a Mediastinal Mass: A Case Report ....................... 253 The Prevalence of Viral Hepatitis and HIV Infections in Patients With Congenital Bleeding Disorders............................ 256 The Use of Botulinum Toxic Injection to Treat Excessive Drooling in Children With Neurological Conditions .............. 258 The Multiple Challenges in the Management of a Patient With HELLP Syndrome, Liver Rupture and Eclampsia .............. 261

Executive DirectorEvan Jenkins, Charleston

Associate EditorsJeffrey B. DeBord, D.O., Martinsburg James D. Helsley, M.D., Morgantown Douglas L. Jones, M.D., White Sulphur Springs Robert J. Marshall, M.D., Huntington David W. McFadden, M.D., Morgantown David Z. Morgan, M.D., Morgantown Martha D. Mullett, M.D., Morgantown Louis C. Palmer, M.D., Clarksburg The West Virginia Medical Journal is published bimonthly by the West Virginia State Medical Association, 4307 MacCorkle Avenue SE, Charleston, WV 25304, under the direction of the Publication Committee. The views expressed in the Journal are those of the individual authors and do not necessarily reflect the policies or opinions of the Journal’s editor, associate editors or its staff, or the WVSMA’s staff. The WVSMA reserves the right not to sell advertising space to any individual, company, group or association whose products or services interfere with the mission and/or objectives of the WVSMA. The WVSMA, in its sole discretion, retains the right to decline any submitted advertisement or to discontinue publishing any advertisement previously accepted. Since the WVSMA is a (501C6), non-profit organization, the Journal does not accept political advertisements for individual campaigns to avoid the appearance of an endorsement which is prohibited by law. The fact that an advertisement for a product, service, or company has appeared in the Journal is not a guarantee by the WVSMA of the product, service or company or the claims made for the product in such advertising. The WVSMA reserves the right to enter into sponsorship and/or marketing agreements that may limit the placement of advertisements for certain products or services.

Subscription Rates:$60 a year in the United States $100 a year in foreign countries $10 per single copy POSTMASTER: Send address changes to the West Virginia Medical Journal, P.O. Box 4106, Charleston, WV 25364. Periodical postage paid at Charleston, WV. USPS 676 740 ISSN 0043 - 3284

Claims for back issues should be made within six months after publication. Microfilm editions beginning with the 1972 volume are available from University Microfilms International, 300 N. Zeeb Road, Ann Arbor, MI 48106. ?2005, West Virginia State Medical Association

Manuscript GuidelinesOriginality: All scientific and special topic manuscripts for the West Virginia Medical Journal will not be considered for publication if they have already been published or are described in a manuscript submitted or accepted for publication elsewhere. All scientific articles should be prepared in accordance with the “American Medical Association Manual of Style.” Authors: All persons listed as authors should have participated enough in the work to take public responsibility for the concept. A cover letter from the corresponding author should be submitted with the manuscript. Format: All articles must be double-spaced and submitted on a CD or an IBM compatible disk with the original, plus one copy of the manuscript. Microsoft Word 97 is preferred, but other languages are acceptable. All tables or figures should be created separately from the body of the manuscript and saved as a jpg, tif, eps or pdf file in a high resolution format on the disk or CD, i.e., Table 1, Figure 1, etc. Legends should be included for all tables and figures. Photographs: Black and white pictures are preferred in a 5 x 7 or 4 x 6 format. Cost of printing photos in excess of four will be billed to the author at a cost of $15 for each one. All photos should have a label pasted on its back indicating its number, the author’s name and an indication of its “top.” Do not write on the back of photos or scratch them with paper clips. Please address articles to the editor at this address only: F. Thomas Sporck, M.D., F.A.C.S. West Virginia Medical Journal P.O. Box 4106 Charleston, WV 25364 If you need more information, phone Nancy L. Hill, Managing Editor, at (304) 925-0342.

NOVEMBER/DECEMBER 2005, VOL. 101

239

President’s Page

Now, the Catch 22The House has finally passed the Conference Committee’s version of the 2005 Deficit Reduction Act freezing Medicare reimbursments at 2005 levels and sacking the linked mandatory Pay for Performance program requirements (for now). CMS has announced it intends to instruct carriers to reprocess all claims that were submitted while the 2006 rate cut was in effect, to reduce administrative burdens on physicians. Now, the Catch 22: it may also mean a wait of several months before physicians receive the lump sum payment (planned for no later than July 1) that will make up the difference in rates paid for January claims already submitted. Since six years of pay cuts are still scheduled to occur, the AMA continues to aggessively seek repeal of the SGR and the establishment of a payment formula based on practice costs. CMS Administrator Mark McClellan, M.D., has also announced, in response to physician feedback that the agency has altered its Physician Voluntary Reporting Program to make it easier for physicians to participate, including reducing the original list of 36 quality measures to 16. CMS is willing to work with the AMA on developing CPT II Codes as an alternative to Gcodes for reporting on the quality measures. He is also considering an extra administrative payment to doctors to cover the cost of reporting. The 16 quality measures include 6 hospital-based measures of practice related to AMI care, surgical antibiotic and thromboembolism prophylaxis and CABG surgery. The other 10 measures relate to office practice and they focus on diabetes, ESRD, protective medications for prior MI, antidepressants for acute major depression, and assessing the elderly for falls. The AMA recommends if your practice is conducive to participating in the CMS voluntary program, the experience would be good preparation for success in the mandatory program predicted to be part of any reimbursement model approved by Congress and may help shape it. Now, the Catch 22: Through the AMA, we have told congressional leaders physicians will not support Pay for Performance without permanent payment reforms. Now, lawmakers say they will not support payment reform without more visible physician willingness to participate in a quality-reporting program. Hmmmm. Stay tuned. Elizabeth L. Spangler, M.D. WVSMA President

240 WEST VIRGINIA MEDICAL JOURNAL

Editorial

Inequity of LifeThe year 2006 was ushered in with great tragedy for our state. Twelve men lost their lives in the Sago mine disaster and the ultimate quality of life for the lone survivor remains undetermined. A few days later, two more miners lost their lives in a Boone County accident. Before the end of the month, there was one more underground fatality and one surface mine fatality. Great media attention was focused on our state and the mining community. This was front page news around the world. Television networks set up camp around the Sago mine and some of the cable networks essentially provided 24-hour coverage of the unfolding tragedy. The predicament of these 12 men became the focus of worldwide attention. Governor Joe Manchin and First Lady Gayle Manchin became the voice and face of West Virginia for the rest of the world. They represented us well with great dignity and composure. Governor Manchin working with state legislative leaders very expeditiously put new mine safety legislation into effect. At the same time, he worked with our federal delegation (Byrd, Rockefeller, Capito, Rahall and Mollohan) to craft and make sure that federal mine safety regulations were passed by Congress. The response to these disasters was incredible. In addition to the legislative and executive actions, the outpouring of sympathy and support for the surviving families from the global community was absolutely overwhelming. Expressions of concern and financial assistance came from around the country and the world. As I have reflected on all of this, I could not help but think of the 40 fatalities that occurred from ATV mishaps in 2005 (180 since 2000). Fifteen percent of these fatalities were children. Most of these unnecessary deaths received little or no media attention other than the perfunctory obituary. These deaths seldom make the front page or even local television news. They certainly get no attention from the national media. Their names are not read in the Legislature. It seems that there is a great inequity of the value of life. What makes a life lost in an ATV accident of lesser value than one lost in an industrial accident. The surviving spouse, children, parents and friends experience just as great an emotional and fiscal loss as those who perish in industrial accidents. HOW MANY LIVES MUST BE LOST IN ATV ACCIDENTS BEFORE ADEQUATE MORAL OUTRAGE LEADS TO MEANINGFUL ATV SAFETY LEGISLATION??? F. Thomas Sporck, M.D. Journal Editor

NOVEMBER/DECEMBER 2005, VOL. 101

241

AMA Delegation ReportThe AMA’s Interim Meeting was conducted in Dallas, November 5-9. The West Virginia delegation included Ahmed D. Faheem, M.D.; Phillip R. Stevens, M.D.; Joseph B. Selby, M.D.; Elizabeth L. Spangler, president of the WVSMA; Evan Jenkins, executive director of the WVSMA, and myself. We had full representation in all Reference Committee sessions, and Drs. David Avery and Gene Cordell, who attended the meeting as delegates for their specialty societies, joined us for our morning delegation session.

Drs.

The opening session of the House of Delegates was highlighted by the AMA President Dr. Ed Hill’s impassioned speech about letting our congressmen understand that the 4.4% Medicare cut would create major access problems for Medicare-age Americans. Following Dr. Hill’s speech, the responses to the AMA’s Member Connect Survey were discussed. This survey revealed that 82% of the AMA’s members stated that the AMA should work with the federal government to ensure that all Americans be required to have, at a minimum, a catastrophic and preventative health care plan. In addition, 78% think that the AMA should also work with the federal government to ensure that individuals with incomes below 200/400% of the poverty level, who are not eligible for Medicaid or SCHIP, be eligible for a tax credit on the purchase of health care coverage. Other results indicated that 69% of the members responding opted out of Medicare provisions; 79% percent endorse banning smoking in food establishments and public places; and 78% advocate physician ownership of all claims, data and medical records information. Many special sessions were presented at the meeting, including one on patient safety which was sponsored by the AMA Group and Faculty Practice Caucus. This session focused on the experiences of 5,700 physician group practices and dealt with changes and adjustments to these practices. Another session that was well attended highlighted wireless technology. In the near future, physicians will be able to use a handheld personal computer that will have access to patients’ medical records and be able to download pharmaceutical information. The devastation caused by the recent hurricanes in the Gulf region was another important topic of discussion. Physicians from the affected states expressed their appreciation to the membership of the House of Delegates, organized medicine and individual physicians for the significant help given to them and their patients during and after the hurricanes. Dr. Don Palmisano, immediate past AMA president, spoke about his personal experiences and said that there was clearly a need for better communication and stronger government leadership. The president of the Louisana State Medical Association, who is from New Orleans, lost all his medical records in Hurricane Katrina. In addition, many volunteers found that the best way to communicate was through text and mobile phone. Dr. Robert Wah of the AMA Board of Trustees felt these experiences overall should lead to wider adoption of health information technology and the need to go digital. The House of Delegates adopted the Council on Ethical and Judicial Affair’s recommendation that describes the responsibilities of physicians and the medical profession participating in public health use of quarantine and isolation measures. The report aims to help physicians adequately balance public health goals with the interest of individual patients during epidemics and natural catastrophes. In closing, I am pleased to report that the AMA is financially in the black. Although membership revenues in 2005 decreased by 1%, they are anticipated to increase by 1% in 2006. The International Medical Graduate Section and the Student and Resident Sections account for the significant increases. Memberships are essential to the overall effectiveness of the AMA. An appeal was made to reach out to all physicians to join the AMA for a stronger voice in these trying days of the profession. Constantino Y. Amores, M.D. Chairman, West Virginia Delegation

242 WEST VIRGINIA MEDICAL JOURNAL

NOVEMBER/DECEMBER 2005, VOL. 101

243

Special Article

Factors Related to Women’s Decisions to Smoke During Their PregnanciesLesley Cottrell, Ph.D.Dept. of Pediatrics, West Virginia University School of Medicine, Morgantown

Ying Wu, Ph.D.Dept. of Pediatrics, West Virginia University School of Medicine, Morgantown

Carole Harris, Ph.D.Dept. of Behavioral Medicine and Psychiatry, West Virginia University of School of Medicine, Morgantown

Christine RomanoWest Virginia Center for End-of-Life Care, West Virginia University School of Medicine, Morgantown

Mark Gibson, M.D.Dept. of Obstetrics and Gynecology, University of Utah, Salt Lake City

Bonita Stanton, M.D.Dept. of Pediatrics, Wayne State University School of Medicine, Detroit

IntroductionPregnancy radically alters the sense of self-identity of both the mother- and father-to-be (1,2). Particularly, a woman’s first pregnancy marks a revolutionary change in her self-identity and in her relationship with, and dependency on, those around her (3). These changes are especially remarkable for adolescents and young adults whose self-identity is still undergoing definition (4); whose actions may be guided in part by rebellion against authority figures in their life (5); and whose concept of intimacy may already be characterized more as self-rewarding than as mutuality (4). For similar reasons, for a young woman, smoking may not simply be a habit or addictive behavior but part of a larger, more dynamic process involving the individual and other relationships which serves as an image-defining event (5). Current tobacco cessation programs continue to focus largely on the act of smoking, with minimal attention to the role that this activity244 WEST VIRGINIA MEDICAL JOURNAL

plays in a woman’s self-concept and in her surrounding social contexts. While showing some limited success, results from existing smoking cessation programs have been disappointing among young, pregnant women (7,8). The recognition on the part of a young mother-to-be that she is as responsible for another being as she is for herself, prompts enormous re-evaluation of self and sometimes results in substantial behavioral changes (9). With her emerging identity challenged by the new role of motherhood, a woman’s perception both of vulnerability to rejection by males (including her current partner) and of her emotional and financial dependence on others, may be greatly heightened (4,10). This alteration in sense of self is especially obvious as she increasingly becomes attached to her growing fetus (11, 12). These concerns may be accentuated by depressive symptoms which are common among young women (13) during their first pregnancy. The increased homogeneity within young female friendship groups with regard to cigarette smoking underscores the important social role of smoking to young women (14). For a young woman, smoking may assume a role far beyond the physical action and addiction; it may play a significant role in shaping her image of herself and defining her relationship to those around her. Buffeted by the pregnancy-related changes in her body, in her sense-of-self, and in her social relations, the stability offered by continued smoking may be all but irresistible. Therefore, while it is perhaps not surprising that many young women do stop smoking during pregnancy (7,8) in response to the need to adapt a healthy lifestyle for their child (8,16), many women do not cease tobacco use (or quickly relapse after delivery (15). This article describes the study we conducted to enable us to design interventions based upon social

dynamics between the new mother and her partner, the radical changes that occur in her sense of self, influential variables within the new mother’s relationships with family and peers, as well as the changes that may accompany tobacco cessation.

MethodsThis study was conducted at the West Virginia University Physician Office Center in Morgantown, W.Va. Information used in the study was collected using two samples: a cross-sectional sample of women who completed a standardized questionnaire (within the first trimester of their pregnancies); and a longitudinal sample of women who completed both the questionnaires and an open-ended interview throughout their pregnancies. The protocol was approved by the West Virginia University Institutional Review Board and all subjects provided written informed consent (assent and parental consent depending on their age). The initial interview (for longitudinal sample) and questionnaires (for both samples) were conducted at the time of the clinic visit after the woman had been seen by her obstetrician. The remaining interviews for those women participating in the longitudinal series were scheduled following the initial interview. The open-ended interview, developed in accordance with the constructs of Protection Motivation Theory (PMT)(17), was administered and audiotaped during the initial physician visit and at 30 weeks gestation. PMT, a social cognitive theory, postulates that there is a balance between costs and rewards for participating in specific behaviors, in this case smoking during pregnancy. Perceived “costs” (severity of untoward outcomes and vulnerability to these outcomes) and “rewards” (both intrinsic and extrinsic rewards of smoking) of the risky behavior are

balanced against the “response costs” and efficacy of the protective maneuver (in this case discontinuing smoking) as well as her perceived ability to affect tobacco abstinence. In addition to each interview, a standardized questionnaire was administered to all participants. The Maternal-Fetal Attachment Scale (11) was utilized to access maternal-fetal attachment during pregnancy, and the Fagerstrom Nictonine Tolerance Scale (18) was used to determine tobacco use and initiation. In addition, measures were selected to gain insight into a woman’s individual attributes that might influence the importance of smoking in her life and/or her dependence on her partner’s approval (11, 19-22). Information obtained from the interviews and the questionnaires were linked with data regarding smoking status at 30 weeks of gestation obtained through chart review. The chart review was conducted by a research assistant blinded as to the responses to the baseline questionnaires. Smoking status as recorded during the 30-week prenatal visit was extracted. Smoking status was confirmed via urine specimen for cotinine dipstick (Status NicotineTM) in order to validate self-reports of use beyond the parameters allowed by the breath analysis. (Urine cotinine levels > 200 ng produce a “positive” test result.)

AnalysesAll tapes were transcribed and entered into ETHNOGRAPH (23,24). Each transcript was coded according to a previously designed coding dictionary based on the PMT constructs, women’s smoking decisions, and the surrounding social context by two reviewers for reliability purposes. Where discrepancies arose regarding coding, a third reviewer was asked to read the transcript. Reviewers also coded for contexts regarding associations and meaning of pregnancy, smoking, body and self-image, locus of control, intimacy maturation, and fetal attachment. The frequency and context of each code word were obtained and reviewed to develop a working paradigm created to better understand the relation between the study variables. Frequency distributions of age, marital status, education levels and baseline smoking status were

calculated to assess the sample characteristics. To assess relations between baseline smoking behavior and the women’s self-reports on the quantitative measures, bivariate analyses were conducted by contrasting mean scores for baseline smokers from those for non-smokers. In order to examine significant predictors of smoking cessation during pregnancy, 47 baseline smokers had their nicotine level checked at 30 weeks of their pregnancy. Smoking status at 30 weeks was determined by the result of a nicotine check (positive/negative). Group mean scores at related items were compared between quitters and cotinine smokers, and the data collected during the first trimester were used. Significance of the group mean score differences were determined using one-sided t-test analyses.

ResultsSixty-eight primiparous women (49 for cross-sectional sample and 13 for longitudinal sample) were recruited for the study, 47 (69%) of who were smokers at baseline (“had smoked one or more cigarettes since learning that they were pregnant). Open-ended interviews were conducted among 45 of these

women, including 27 smokers and 18 non-smokers. The mean age of the women was 19 years; 19% were married and 28% were living with a boyfriend. All but 10% had completed at least junior high school; 71% had completed high school. The cross-sectional sample contained 23 women, of which 32% were smokers. The mean age of women in the cross-sectional sample was 20 years; 26% were married and 75% had completed high school. Table 1 displays relations between participant perceptions identified as being key to the PMT and/or relative to women’s decisions regarding smoking during their pregnancies and participant smoking status at baseline. Compared to smokers, women who did not smoke at baseline demonstrated a more internal locus of control regarding general parenting practices (p < .03) and a greater acceptance of authority (p < .05). Views of authority, in particular, were also reflected in the interviews of these women. One smoker noted that “I can stand up on my own,” and in her later interview reported that she wanted “to reach that point I don’t need to depend on anybody. She also stated “I don’t need to depend on anybody. ... In general in life, people let me down.”NOVEMBER/DECEMBER 2005, VOL. 101 245

Smoking CessationOverall about one-half (53%) of women who smoked at the beginning of pregnancy ceased smoking by the time they gave birth. Although the cohorts were comparable at baseline, rates of smoking cessation among the women who participated in the qualitative, longitudinal interviews were significantly higher (71%) than among women who had not been invited to participate in the interviews (25%, p < .01). Characteristics differentiating baseline smokers who abstained from smoking at 30 weeks from those who did not are shown in Table 2. Women who stopped smoking at 30 weeks had a lower baseline consumption of tobacco (p < .05), were less likely to smoke in the morning (p < .05), to miss the first cigarette of the morning (p < .01), to smoke when ill (p < .01) and had an overall lower Fagerstrom Nicotine Score than women who were still smoking at 30 weeks. Women who stopped at 30 weeks were also less tolerant of their partner’s smoking at baseline than women who continued to smoke. These women also reported more confidence regarding having the ability to quit smoking within the next month. The participants who smoked when “angry or frustrated” (p < .02); “for themselves” (p < .05); “to feel more comfortable with others (p < .01); or ”out of boredom” (p < .05); were less likely to stop smoking than their counterparts who did not express these feelings. Analysis of the “Smoking Questionnaire” revealed that women who were still smoking at 30 weeks reported a higher baseline use of smoking to manage negative emotional states than women who had quit by 30 weeks (Management of Emotions subscale score, 9.76 vs. 7.69, p = .016). Likewise, women who were still smoking at 30 weeks reported a more negative appraisal of their smoking (by themselves and others) at baseline than women who quit by 30 weeks (Negative Appraisal Subscale-Score, 4.65 vs. 10.81, p = .05). Women who were still smoking at 30 weeks made more positive attributions to smoking at baseline than women who quit by 30 weeks (Positive Appraisal subscale score, 15.82 vs. 12.44, p = .005). The encouragement for smoking cessation246 WEST VIRGINIA MEDICAL JOURNAL

(by partner, family, and friends) did not differ significantly between smokers and quitters at 30 weeks (6.38 vs. 7.21, p = .21). Additional themes not assessed in the standardized questionnaires emerged in the qualitative interviews. Women expressing a physical aversion to smoking were universally able to stop smoking during pregnancy. Likewise, an aversion to the image of a pregnant woman smoking was correlated with a high cessation rate. While most partners expressed a desire for the women to cease smoking, this did not predict the

women’s ability to do so; likewise, while only about 1/3 of women expressed feelings of being supported by their partner, this perception did not correlate with the ability to quit. All women in our study were aware of the health consequences of smoking and all of them wished to stop smoking.

DiscussionThe relation between women’s views of authority and their report of others’ views of smoking during pregnancy is not surprising given that

previous research in other areas of risk behavior have shown resistancy or increased risk among adolescents and younger adults when faced with unacceptable attitudes of others (25, 26). However, this finding argues toward the consideration of a woman’s relationship and acceptance of others to determine the success of a program and an appropriate treatment approach. As shown in Table 1, the smoking behavior of women who accept authority views may also be influenced by other factors including perceived level of impact to the baby’s health, her own perceptions of smoking during pregnancy, nicotine dependence and any experienced physical aversions toward smoking during pregnancy. This study shows that women who accept the views of authority figures typically stopped smoking during their pregnancy, but resumed smoking in the postpartum period perhaps because other individual factors were impacting their decisions. Most of the individual factors in Table 1 are tied specifically to the time frame of the pregnancy. For example, a woman may perceive smoking to be a significant health threat to her baby during her pregnancy, but after the baby is born she may resume smoking. Similarly, while weighing the craving of nicotine against the health risks during pregnancy, a woman may stop smoking because the health risk outweighs her dependency; however, after the birth, her perceptions change. These findings support the inclusion of education on the affects of smoking in the postpartum period (e.g., secondary smoking affects; breastfeeding) among women who are planning to have children or who are pregnant.

ConclusionSince women who continue to smoke while pregnant already have higher negative self-appraisals of their own smoking, this theme should not be stressed in smoking cessation interventions. These women had a higher tobacco at baseline and therefore may have encountered more negative reactions. In addition, “feeling bad” produces an increased desire to smoke to manage negative emotions. It is also important to note the finding that women who participated in the longitudinal interviews were significantly more likely to discontinue smoking. This suggests that these interviews may be a powerful intervention in and of themselves. The characteristics of this examination that led to an increase in smoking cessation among these women remain unidentified. Many findings of this study suggest that a direct or somewhat forceful approach to smoking cessation programs would not be successful among pregnant women. Since many women may be re-evaluating themselves and their role within their environment, programs designed from general profiles may also be futile.

This research was supported by the Robert Wood Johnson Foundation (ID/#040676). We gratefully appreciate Denise Knoebel, M.S.W., M.P.H., Shirley Tennant, L.P.N., and Douglas Glover, M.D., for their collaboration on the implementation of this project. We also thank all of the women and men who participated in the study and the clinic staff.

IntroductionVascular compromise is an uncommon cause of hand pain (1). In patients evaluated at the primary care level, disorders of the musculoskeletal system are the number one cause. When evaluating a patient presenting with hand pain, a thorough examination of the neuro-vascular system is of paramount importance. The primary manifestations of upper extremity ischemia are arm claudication, rest pain, ischemic ulceration or coldness and color changes of the hand and digits (1). Most patients who present with symptomatic upper extremity digital ischemia, have a medical illness that precipitates and/or exacerbates their condition. Vasospastic disease of the hand in the absence of systemic illness is referred to as Raynaud’s disease. In the presence of systemic illness, especially auto-immune disorders, it is referred to as Raynaud’s phenomenon (2). Patients who have a surgically correctable arterial lesion at the level of the hand and forearm make up a small minority (3). Identifying this group is based on suspicion, careful physical exam, knowledge of the patient’s past as well as current occupation, and elimination of the possibility of precipitating medical conditions. Up to 25% of hand injuries can be attributed to overuse. Wrist and hand overuse syndromes are broadly classified into tenosynovitis of the wrist and hand, nerve entrapment syndromes and overuse vascular syndromes (4). Overuse vascular syndromes may manifest as digital ischemia, hypothenar hammer syndrome, ulnar artery thrombosis and arterial aneurysms.

Adam E. Perlmutter, D.O.Resident, Dept. of Surgery, West Virginia University School of Medicine, Morgantown

Bruce G. Freeman, M.D.Associate Professor and Chief, Dept. of Plastics and Reconstructive Surgery, West Virginia University School of Medicine, Morgantown

AbstractAlthough rare, vascular insufficiency is a well-recognized cause of hand pain, making a significant impact in the athletic and labor industry. Surgically correctable lesions are important to recognize since definitive treatment may alter the course of the disease and affect outcomes. Hypothenar hammer syndrome (HHS) results from anatomic predisposition and exposure to acute and chronic stress. Arteriography is the gold standard of diagnosis and severe symptomatic cases are treated with surgical resection and re-establishment of blood flow. We report such a case of HHS, its clinical course and management.

complaints of pain in the little, ring and long fingers, numbness and discoloration of the right hand. He had been experiencing this pain for about two weeks. There were no symptoms pertaining to the left hand, no previous trauma to the hand or upper extremity, no positional changes or mo change with altered environmental temperature. He had an unremarkable medical and surgical history, and did not take any medications. He was a smoker. On exam, the blood pressures in both his arms were similar. His respiratory, neurological and abdominal exam was unremarkable. He had a regular cardiac rhythm and had normal carotid, brachial, radial, ulnar and femoral pulses. There were no radio-femoral or radio-radial delays. His right little, ring and long fingers had cyanosis, and the capillary refill time was 4 seconds, compared to 2 seconds in the right thumb. Allen’s test showed complete radial dominance. His workup consisted of upper extremity segmental pressure waveform, followed by an upper extremity arteriography with digital run off. Noninvasive segmental pressure evaluation studies revealed relative ischemia of the affected digits (Figure 1, Table 1). The arteriography of the aortic arch and right upper extremity showed normal vasculature to the level of wrists, where, as expected a segmental occlusion was identified (Figures 2, 3, 4).

Clinical and Surgical CourseThe diseased segment of the right ulnar artery was resected and the contralateral basilic vein was used to create an interposition graft. The post operative course was unremarkable. The patient reported relief of symptoms and was discharged home on aspirin. At follow up, he was symptom free and his digital pressures were normal.

Case reportA 50-year-old, right-handed, Caucasian male, who was a driller in the coalmines, presented with250 WEST VIRGINIA MEDICAL JOURNAL

DiscussionIn contrast to lower extremity disease, upper extremity vascular disease is uncommon but potentially disabling because of its effect on hand function. It carries a worse prognosis if it is secondary to an underlying systemic disorder (1). Since persistent ischemia is a potential cause of increasing morbidity, early diagnosis is the key, specifically of disorders that have a surgical remedy. The ulnar and radial arteries are the principal blood supply of the hand. The ulnar artery provides the dominant supply of oxygenated blood to the ulnar three and a half digits, and the radial artery, the thumb and the radial side of the index finger (7). The two main vessels contribute to the formation of the palmar arterial arches, the superficial and the deep (5,6,7). Circulation can be compromised with conversion from a complete arch to an incomplete one with disruption of blood flow in either the ulnar or the radial artery (7). The ulnar artery accompanies the ulnar nerve in its passage through the Guyon’s canal, an unyielding tunnel bordered by the hook of the hamate, pisiform bone, piso-hamate ligament and the volar carpal ligament. The artery and nerve are most vulnerable to trauma slightly distal to the pisiform because the artery in this area lacks a fascial covering, is located superficially and is in close proximity to the hook of the hamate. Repetitive stress exposes this vessel to injury and potential vascular induced hand pain (7). Long before its description in athletes, the syndrome resulting from acute and chronic damage to the ulnar artery at the level of the wrist was causing pain and functional impedance in people using their hands as hammers. Earliest descriptive reports can be traced back to the Von Rosen account in 1934, which was published in Scandinavia. He wrote that repetitive blunt injury resulted in damage to the arterial intima and subsequent thrombus formation (8). It was not until 1970 that the term hypothenar hammer syndrome was used in medical literature. Conn et al used this term to describe the signs and a symptom associated with digital ischemia secondary to repetitive blunt trauma as striking of the hypothenar

Figure 1. Segmental arterial waveform analysis of the right and left extremities. Note the flat line pulse volume recording of the long finger in the right hand. Table 1. Noninvasive Segmental Pressure Evaluation Studies Indicate Relative Ischemia of the Affected Digits.

eminence hammers the distal ulnar artery and superficial palmar arch against the hamate bone (9). Today, hypothenar hammer syndrome (HHS) is a well-recognized clinical entity with references in plastic surgery, cardiovascular surgery and sports and occupational medicine literature. HHS can result from a multitude of occupational and recreational activities. The ischemia occurs due to: 1) intimal damage and thrombosis; 2) altered blood flow due to either true aneurysm formation, in which all layers of the vessel wall are injured, or false aneurysm secondary to a laceration or penetration of the vessel wall with encapsulation and hematoma formation; and 3) vasospasm secondary to changes in the arterial flow pattern.

Workers most at risk are mechanists, construction workers, carpenters, butchers, metal works and truck drivers. Sportsmen most as risk are judo, karate, baseball catchers, lacrosse, hockey, tennis and mountain bikers (9,10,11,13). A clue to diagnosis is a history of palmar trauma (12). A positive Allen’s test depends on presence of ulnar artery thrombosis and whether arterial arch exists. Doppler examination, digital plethysmography and pulse volume recording, B-mode ultrasonography and radionuclide flow studies will aid in the diagnosis. The gold standard for diagnosis, prognosis and treatment planning is upper extremity arteriography. An arteroigram is necessary to exclude a proximal embolic event, delineate the extent of ulnar artery involvement, and define the palmar arch anatomy as well as determine the extent of digital artery involvement (12). The radiologic signs of HHS are tortuosity, aneurysm formation, segmentalNOVEMBER/DECEMBER 2005, VOL. 101 251

occlusion, absence of a complete palmar arterial arch and diffuse luminal irregularities. Treatment modalities encompass observation, mechanical protection and padding, risk factors (especially nicotine consumption) modification, cervical sympathectomy, thrombolysis and resection without or without reconstruction (3,9,14). For severe symptomatic disease, the standard of care is resection of the aneurysm or thrombosed segment of the ulnar artery with vein graft reconstruction by a hand surgeon skilled in microsurgical technique. This prevents the recurrence of digital artery embolization. Regional thrombolysis is a valuable neo-adjunct and it is known to enhance digital print-outs. Asymptomatic ulnar artery occlusions do not need surgical intervention (15).

Giant Aneurysm of the Saphenous Vein Graft Presenting as a Mediastinal Mass: A Case ReportRajendra Shetty, M.D. Abnash Jain, M.D. Robert Beto, M.D. David Massinople, M.D. Reyaz Haque, M.D.Dept. of Medicine, Section of Cardiology, West Virginia University School of Medicine, Morgantown

IntroductionCoronary venous bypass graft aneurysm is a rare, but well-recognized complication after coronary artery bypass grafting. We present a patient diagnosed with a giant aneurysm and thrombus of the vein graft to the right coronary artery who subsequently underwent a catheter-based approach to occlude the aneurysm.

Case ReportA 71-year-old male with a known history of coronary artery disease and two coronary artery bypass graftings, was found to be tachycardic on a visit to his primary care physician. Chest X-ray showed a rounded irregularity of the right lateral aspect of the cardiac silhouette. He subsequently underwent a transthoracic echocardiogram that was interpreted as a right atrial mass. Further diagnostic evaluation included a computed tomographic scan and magnetic resonance scan of the chest. These scans revealed a dilated right atrium, which was again interpreted as being completely filled with a mass. He was transferred to the cardiothoracic surgery service at West Virginia University Hospital in Morgantown for exploration and possible resection of this mass. As part of the preoperative workup, he underwent a cardiac catheterization to assess the need for repeat bypass. Coronary angiography and bypass graft study revealed the vein graft to the right coronary artery to be diffusely ectatic and terminating in a large aneurysm (Figure 1). There was flow from the bypass graft supplying this aneurysm, however, there was no retrograde filling of the aneurysm. In addition, there was no antegrade flow and no evidence of distal filling of the native coronary circulation. Right atrial injection of contrast at the junction of the inferior vena cava and right atrium revealed a filling defect in the

Ansar Rai, M.D.Dept. of Radiology, Section of Neuroradiology, West Virginia University School of Medicine, Morgantown

AbstractWe report a patient who presented initially with a diagnosis of a mediastinal mass. During the cardiac catheterization, the patient was diagnosed with a saphenous vein graft aneurysm. We proceeded with a catheter-based intervention resulting in occlusion of the aneurysm. Repeat angiogram after three months showed complete occlusion of the vein graft supplying the aneurysm. We believe that in selected patients with saphenous vein graft aneurysm a catheterbased procedure is feasible and successful.

right atrium representing a vein graft aneurysm impinging on the right atrium. We subsequently performed a trans-esophageal echocardiogram that showed a large round mass with extrinsic compression of right atrium (Figure 2). After evaluating the therapeutic options with the cardiac surgeons, we decided on a catheter-based interventional strategy to occlude the aneurysm and relieve the right atrial compression. Placement of coil to create embolization of the saphenous vein graft aneurysm was considered feasible; a covered stent was not an option as there was no distal flow into the native circulation. An 8-French guiding catheter was placed at the vein graft ostium. Subsequently, a 0.021 mm microcatheter was navigated through the guiding catheter into the vein graft and positioned where there was a distinct caliber change in the vein graft. Continuous flush was established through the micro and the guiding catheter. Subsequently two, 8 x 24 coils were placed, followed by three fibered coils. Repeat injections demonstrated almost complete occlusion of the aneurysm with minimal (less than 5%) flow seen in the aneurysm (Figure 3). The patient underwent a repeat cardiac catheterization three months later that showed the saphenous vein graft totally obstructed at the point of coil implantation.

DiscussionSaphenous venous graft (SVG) aneurysm is a rare complication of CABG. Delayed development of coronary pseudoaneurysm after interventional treatment of coronary arteries has also been reported(3, 4). The cause and location can differ between true aneurysm and pseudoaneurysm, but clinical presentation and size do not. True aneurysms usually present several years after CABG; two patient reportsNOVEMBER/DECEMBER 2005, VOL. 101 253

Figure 4. Follow up aortogram after three months (RAO projection) shows total occlusion of the RCA graft by the coils. AO = Aortogram; C = Coil.

Figure 3. Angiography (LAO projection) of vein graft after coil embolization. C = Coil, VG = Vein Graft.are available in literature of cases presenting in six months (7,8). Pseudoaneurysms are thought to be caused by weakness of the graft anastamosis, leading to suture rupture. Aneurysms are often associated with the risk of sudden death from rupture, arrhythmia, and cardiac tamponade (5). In asymptomatic patients, diagnosis is difficult. Some patients present with angina-like presumed secondary to254 WEST VIRGINIA MEDICAL JOURNAL

stenosis, microembolism, or compression. The diagnosis of vein graft aneurysm may be made by computed tomography, magnetic resonance imaging or echocardiography. Coronary angiography should be performed to determine vein graft patency and native coronary anatomy. Coronary angiography may be diagnostic in itself as in our patient, since occasionally computed tomography has misinterpreted SVG aneurysms as solid masses (9,10). Our patient demonstrates an unusual presentation of SVG aneurysm as an right atrial mass. Surgical excision of SVG aneurysm and revascularization has led to a successful outcome in the past (1), but carries a high risk and morbidity.

ConclusionIn conclusion, SVG aneurysm needs to be considered in the differential diagnosis of a patient who has undergone bypass surgery and presents with a mediastinal mass. Coil embolization with a catheterbased approach is a feasible treatment modality.

The Prevalence of Viral Hepatitis and HIV Infections in Patients With Congenital Bleeding DisordersSteven J. Jubelirer, M.D.Senior Research Scientist, CAMC Health Education and Research Institute, Charleston; Clinical Professor of Medicine, West Virginia University School of Medicine, Charleston Division

IntroductionIn 1984, the Center for Disease Control (CDC) established the Hemophilia Surveillance System (HSS) in six states throughout the United States. Their mission was to review medical records of persons with Hemophilia A and B with transfusion–associated infections to monitor medical and clinical outcomes (1). Over four years, the HSS collected data on clinical risk factors associated with HIV and Hepatitis A, B, and C. Since that time, the U.S. Congress mandated the CDC to reduce or prevent viral complications of persons with clotting disorders. In response, the CDC has collaborated with approximately 140 federally funded Hemophilia Treatment Centers (HTCs) in the U.S. and its territories through the Universal Data Collection (UDC) surveillance project to monitor blood product safety and detect new viral hepatitis and human immunodeficiency virus (HIV) infections (2). From May 1998 – June 2002, a total of 11,171 patients with hemophilia and other bleeding disorders were enrolled by CDC nationwide; 62% with hemophilia A, 16% with hemophilia B, 19% with von Willebrands’ Disease (VWD), and 3% with other congenital bleeding disorders (2). At the HTC located at Charleston Area Medical Center (CAMC) in Charleston, W.Va., 44 volunteer patients seen during this period met eligibility criteria for UDC monitoring. This article describes data collected on these 44 patients.

AbstractPatients with clotting disorders, including hemophilias A and B, and von Willebrand Disease generally receive pooled human blood products, and are at high risk for HIV-1 and hepatitis A, B and C viral infection. This retrospective study describes patients receiving treatment at a federally funded Hemophilia Treatment Center (HTC) from 1998 – 2002 and assesses the prevalence of viral infection. In addition, current rates of viral infection are compared to 1984-1996 rates.

Materials and MethodsTo be eligible for the UDC surveillance project, the patient must be at least two years of age with a congenital bleeding disorder due to a congenital deficiency or acquired inhibitor in which any of the coagulation proteins is missing,256 WEST VIRGINIA MEDICAL JOURNAL

reduced, or defective and have a functional level less than 50%. Patients two years or older with a physician’s diagnosis of von Willebrands’ Disease (VWD) are also eligible. Patients with a diagnosed platelet disorder, thrombocytopenia, or coagulation protein deficiency due to severe liver disease are ineligible (2). HTC staff obtained informed consent from each UDC participant and collected a standard set of clinical data and a plasma specimen. Data presented on standardized registration, annual, and laboratory forms are sent to the CDC along with annual blood specimens from all UDC patients. Specimen remainders are stored in a blood-safety repository for future investigations. UDC participants are tested for HIV 1 and 2, and Hepatitis A, B, and C at enrollment according to algorithms that determine whether patients have been exposed to or infected with a virus. Participants who test negative for a virus are retested in subsequent years to monitor for seroconversions. HIV results are reported as “positive,” “negative,” or “indeterminant” by enzyme-linked immunosorbent assay (ELISA) and Western Blot testing. HIV-2 results are reported only if positive. Possible seroconversions are evaluated for Hepatitis A Virus (HAV) by testing for IgM antibody to HAV and total antibody to HAV; for Hepatitis B virus (HBV) by testing for antibody to Hepatitis B surface antigen (anti-HBs); antibody to Hepatitis B core antigen (anti-HBc), and Hepatitis B surface antigen (HBsAg); and for Hepatitis C Virus (HCV) by testing for antibody to Hepatitis C (anti-HCV), which is confirmed with recombinant immuno blot assay and/or HCV-RNA by polymerase chain reaction as needed.

ResultsDuring May 1998 – June 2002, a total of 44 patients with hemophilia and other bleeding disorders who

were seen at the CAMC hemophilia treatment center were enrolled in the UDC surveillance project; 21 (48%) had hemophilia A, 19 (43%) had hemophilia B, and 4 (9%) had VWD. None of the patients tested between 1998-2002 exhibited an acute hepatitis A infection. In addition, no patients who seroconverted to Anti-HAV were IgM-positive when the tests were performed. IgM positivity is a marker of acute infection with HAV that persists for 3-6 months in the majority of patients. Of the 35 patients who seroconverted to total Anti-HAV during the testing period, all had completed the Hepatitis A vaccination series, received a booster injection, or were in the process of being vaccinated. No chronic cases of Hepatitis B were identified during the study. Of the 32 persons who were tested for Hepatitis B and seroconverted to one or more HBV markers, all seroconverted only to Anti-HBs, indicating vaccination or natural immunity. The remaining 12 had tested negative in initial CDC testing for Anti-HBs, Anti-HBc, or HbsAg. They will be retested in subsequent years. Twelve of 44 patients (27%) were infected with Hepatitis C Virus. All were age 20 and older, and were infected from blood products used before enrollment in UDC. Five patients (11%) were positive for HIV infection. All patients with HIV had severe hemophilia A (factor VIII level d?1%) and were co-infected with Hepatitis C. All patients with HIV were born before 1975. In a prior study of patients at CAMC’s HTC between 1984-1996, 54% of tested patients had Hepatitis B infection, 87% Hepatitis C, and 33% HIV. In that study, all HIV-1 infected individuals had hemophilia A and the risk of HIV infection increased in those age 30 and older.

Table 1. Comparison Between Disease States and Time Periods for the Populations at the Hemophilia Treatment Center.

at CAMC between 1998–2002 compared to those treated from 1984- 1996 (Table 1). This reduced prevalence is the result of several contributing factors such as: 1) more frequent vaccinations for Hepatitis A and B. Since 1998, all patients at the HTC have received Hepatitis A and B vaccinations; 2) reduced risk for viral infections (including HBV, HCV, and HIV) associated with viral inactivation procedures for clotting factor concentrates (4); and 3) premature death due to AIDS prior to 1998 and the development of more effective antiretroviral therapy. Hemophilia Treatment Centers provide care to 70% of persons in the United States with bleeding disorders (5). The UDC surveillance project is the largest data collection system monitoring persons receiving clotting factor concentrates, and infections transmitted by these products are often identified first in this population (2). Therefore, the UDC project promotes prevention and reduction of the complications of bleeding disorders and provides the HTCs with timely risk data to support policy decision making. In addition, the creation of the UDC surveillance project has resulted in high levels of vaccination coverage which is recommended for persons with bleeding disorders (6,7).

DiscussionOur study suggests that the prevalence of HIV, Hepatitis B, and Hepatitis C has decreased in clotting disorder patients treated at the HTC

NOVEMBER/DECEMBER 2005, VOL. 101

257

Scientific Article

The Use of Botulinum Toxic Injection to Treat Excessive Drooling in Children With Neurological ConditionsAtiya Khan, M.D.Neurologist, Fort Wayne Neurological Center, Fort Wayne, Ind.; and Former Assistant Professor, Dept. of Neurology, West Virginia University School of Medicine, Morgantown

IntroductionDrooling or excessive salivation is seen in many chronic childhood neurological conditions such as cerebral palsy, post traumatic or post anoxic encephalopathy, and brain malformations. It usually results from a disturbance in the neuromuscular coordination of swallowing. Other factors include increased production of saliva, dental malocclusion, postural problems and an inability to recognize salivary spill due to sensory dysfunction. Treatment for this disabling complaint has generally been unsatisfactory. We report our experiences using the new treatment modality of botulinum toxin injection into the parotid glands for this condition using a few illustrative cases.

Gauri Pawar, M.D.Assistant Professor, Dept. of Neurology, West Virginia University School of Medicine, Morgantown

AbstractDrooling is a frequent complaint in children with chronic neurological conditions. This is due to poor neuromuscular coordination of the oropharyngeal musculature. Treatment options such as anticholinergic medications and surgical treatment have generally been unsuccessful or associated with side effects and complications. A new treatment for these children is botulinum toxin injection into the parotid glands to decrease saliva production. This article reports on two cases in which this modality was effectively utilized to treat this neurological condition.

ganglia damage and subsequently developed seizures. She had a tracheostomy tube and G-tube placement for feeding. She had profuse drooling since she was unable to swallow her saliva. Glycoyrrolate was tried without much success. She subsequently was admitted with aspiration pneumonia. In clinic, she was noted to have almost continuous dribbling of saliva onto her chin and bib. We treated her with botulinum injections to the parotids and there was a significant improvement in her drooling when she came to the clinic for her return visit. Her mother and home nurse were pleased with the result.

DiscussionDrooling is a common complaint in many chronic neurological conditions during childhood. It can lead to major hygienic and psychosocial difficulties for the patients and their caregivers including maceration of the skin around their mouth, chin and neck, which may result in secondary bacterial and fungal infection. It can also cause body odor, embarrassment poor self-esteem, as well as interfere with speech and feeding. Caregivers in daycare and teachers often complain that other parents are concerned about the patient drooling on toys and other children. This at times can be quite socially disabling. Extra time is involved in the care and hygiene of the patient including frequent bib and clothing changes and frequent bathing requirement. The clothing of the caretakers and siblings, and furniture, carpets, and bedding are often soiled with the patient’s saliva. In addition, there is concern about dehydration, aspiration and aspiration pneumonia, particularly at night in children with excessive pooling of saliva and choking. Salivary glands are controlled by the autonomic nervous system. They

First Case ReportA 4-year-old, mentally retarded and hyperactive boy with a history of pervasive developmental disorder thus far unexplained by any genetic, metabolic or neurological syndrome was suffering from profuse drooling. He had no expressive language. His mother reported that he needed multiple clothing changes in the day because of constant “wet shirt front.” She also reported that daycare facilities had reported concerns because of his drooling on toys, carpet and other children. He usually had a macerated chin and neck. After explaining the procedure, we injected him with botulinum toxin in his parotid glands. At his follow up appointment, his mother was extremely pleased with the results and his condition was visibly improved.

Second Case ReportThis patient was a 6-year-old girl who was a near drowning victim at age 2 and 1/2 years. She had sustained severe cortical and basal258 WEST VIRGINIA MEDICAL JOURNAL

are primarily under parasympathetic control mediated by the adrenergic and cholinergic nerve endings. Adults produce about 1,000 to 1,500 ml of saliva daily mainly in the parotids, submandibular and sublingual glands. The lingual and other minor glands produce about 5% of this saliva, with the parotids and the submandibular glands producing about 45% each. Current treatments for sialorrhea include anticholinergic drugs such as glycopyrrolate, benztropine and scopolamine (1). These are often ineffective and may produce unacceptable side effects such as blurred vision, sedation urinary retention, and cardiac arrhythmia. Interventions like salivary duct ligation, duct rerouting, salivary gland excision and local irradiation are other more effective and permanent options (2), but these are invasive and usually not performed on children. With local irradiation, there is concern for local side effects and increased risk of malignancy after 10 to 15 years. The anaerobic bacteria Clostridium botulinum produces neurotoxins that block neuromuscular transmission by inhibiting the release of acetylcholine at the neuromuscular junction, resulting in both skeletal and smooth muscle paralysis. These toxins also act on glands decreasing production of sweat and saliva. It has been demonstrated in experimental animals that injection of botulinum toxins decreases saliva production. In addition, dry mouth is a symptom of botulism. C. Botulinum produces 7 serologically distinct neurotoxins designated A to G. Multiple proteins in the nerve terminal mediate the exocytic release of acetylcholine (3,4). Cleavage of any of these proteins leads to inhibition of acetylcholine release. Botulinum toxin types A and E cleave SNAP-25, a cytosolic protein attached to the presynaptic membrane; toxin types B, D, and F cleave synaptobrevin; and VAMP, a protein in the acetylcholine containing vesicle membrane and toxin type C cleaves syntaxin, a cytosolic protein in the presynaptic membrane. Currently toxins are produced by culturing and then fermenting C. botulinum. This leads to lysis and toxin release. Type A toxin is purified,

crystallized with ammonium sulfate, diluted, and finally freeze-dried. It must be diluted with preservative-free saline prior to use. Toxin type B is kept in solution at pH 5.6. It should be kept in the refrigerator and should not be frozen. The potency of the toxin is expressed in mouse units, with 1 mouse unit being LD50 for mice. Type A toxin is packaged as 100 units per vial, whereas, type B toxin is packaged in 2,500, 5,000 and 10,000 unit vials. Botulinum toxin type A injections into the salivary glands for treatment of sialorrhea in patients with cerebral palsy, Parkinson’s disease, amyotrophic lateral sclerosis and other neurological disorders has been reported (5-9). The parotid is easily accessed from the surface and most injections are done using surface landmarks. There are several reports on ultrasound-guided injections into the parotid and submandibular glands (10-12). In most studies, beneficial effect was found after 3-10 days of injection and response lasted about 4-5 months. Side effects of botulinum toxin injections are mainly localized to the region injected. At the time of injection, local stinging and bruising may occur. Since the toxin can spread into the neighboring facial and jaw muscles, facial weakness can be noted. Difficulty in chewing food, biting the sides of the mouth, dysarthria, dysphagia, or change in speech has also been reported after jaw muscle injections (13,14). These effects develop after a few days and are transient. Patients have rarely required temporary nasogastric tube feeding. In addition, systemic side effects have also been reported such as transient flu-like symptoms with fever, chills, generalized weakness, malaise and fatigue. These are selflimited, but can last a few weeks. No clinical cardiovascular symptoms have occurred with the injections although significant changes in respiratory and heart rate variation have been reported (15). The distant effects of botulinum toxin type A were investigated using electromyography. Toxin injections in the neck or face can result in remote neuromuscular effects in the limbs, but these effects were not clinically significant (16,17,18). There are rare reports of systemic botulism-like

reaction to botulinum type A injections (19). In addition, idiosyncratic reactions to botulinum toxin type A injections are very rare. Although there are no reports of long-term injections for sialorrhea, reports on use for movement disorders indicate that patients have remained responsive for more than 15 years. While dosage adjustments may be needed over time, this is likely related to change in the phenomenology of the movement disorders. Another concern is immunoresistance with development of antibodies with chronic use of botulinum toxin (20). Chances of development of antibodies are estimated to be greater if injections are done less than 3 months apart. The dose of botulinum toxin should be individualized for each patient. Since there is no way to reverse the effect of the toxin once injected, it may be prudent to use a smaller dose when beginning treatment and subsequently adjusting the dose according to response. It may take 2-3 injection trials before the full desired effect is seen. For drooling, botulinum toxin should be given as a single injection into the body of the parotid. The injection site is about .5 to 1 cm in front of the tragus, depending on the size of the child, and the needle should be inserted .25 to .5 cm. The toxin diffuses into the parotid. Prior to injection, the procedure, side effects, and benefits should be explained to the parents. Parents should understand that toxin injection is not a cure and that repeat injections are required for continued effectiveness. No routine laboratory testing is required, either before or after botulinum injections. If a patient who had initially been responsive stops showing the desired effect, antibodies to the toxin can be tested. Parents should be asked to keep a close watch on salivation and asked to keep written notes as to the effects. If possible the child should be seen in about a month to assess the effectiveness of the dosage. The subsequent injections should be at the longest possible intervals.

ConclusionExcessive drooling can be a disabling problem in many children with neurological conditions. A teamNOVEMBER/DECEMBER 2005, VOL. 101 259

approach for treatment is ideal and may include medications, dental, orthodontic, surgical speech therapy and occupational therapy interventions. The new treatment option of using botulinum toxin injection into the parotid gland can be useful in the therapeutic armamentarium for this condition. Although invasive, it is relatively safe and well tolerated by children.

The Multiple Challenges in the Management of a Patient With HELLP Syndrome, Liver Rupture and EclampsiaCraig S. Herring, M.D.Obstetrician/Gynecologist, Private Practice, Carlisle, Pa.; Former Chief Resident, Dept. of Obstetrics and Gynecology, Charleston Area Medical Center, Charleston

IntroductionPreeclampsia remains one of the most important unsolved problems in obstetrics (1). This condition can cause significant maternal and fetal complications. This report illustrates the many challenges obstetricians face when they manage patients with severe preeclampsia and HELLP syndrome complicated by the life-threatening condition of liver rupture. Multiple medical and surgical therapeutic interventions were necessary to achieve hemostasis, including the use of recombinant factor VIIa. In a previous report, recombinant factor VIIa was used in three cases of liver hematoma and HELLP syndrome (2). There were no neonatal survivors. In our case, both mother and neonate were treated successfully.

S. Greg Heywood, M.D., F.A.C.O.G.Director, Residency Program, Dept. of Obstetrics and Gynecology, Charleston Area Medical Center and West Virginia University School of Medicine, Charleston Division, Charleston

Christos G. Hatjis, M.D., F.A.C.O.G.Vice Chairman of Maternal-Fetal Medicine, Children’s Hospital Medical Center of Akron, Ohio; Professor of Obstetrics/Gynecology, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio; and Former Professor and Chairman, Dept. of Obstetrics and Gynecology, West Virginia University School of Medicine, Charleston Division, Charleston

AbstractWe report a case of a patient with HELLP syndrome, hemorrhagic shock due to liver rupture and late postpartum eclampsia superimposed on lupus nephropathy and chronic hypertension. This patient was delivered at 26 weeks by C-section. Aggressive and complex surgical and medical treatments were necessary to achieve hemostasis and stabilize the patient. She recovered and was discharged to home on the 24th postpartum day in good condition. The premature baby was discharged home in fair condition on the 131st hospital day.

Case ReportA 29-year-old Gravida 3, Para 2 was transferred at 26 1/7 weeks gestation with complaints of abdominal and right shoulder pain. She had a history of chronic hypertension associated with lupus nephropathy and a history of thrombophlebitis (DVT). She was taking prednisone 10 mg p.o.q.d. for SLE, alpha-methyldopa 250 mg p.o.t.i.d. for hypertension, and enoxaparin 40 mg SQ q.d. for DVT prophylaxis. She had previously given vaginal birth to two full-term infants, but both pregnancies had been complicated by lupus nephropathy and hypertension. Her blood pressures were in the 180s/120s torr. The abdominal exam revealed severe right upper quadrant pain and guarding. She had no vaginal bleeding and her cervix was closed. Fetal heart rate was in the 130s bpm with acceptable long-term variability. There were no contractions. Laboratory studies revealed a picture consistent with HELLP syndrome. Her serum creatinine was 2.9 mg/dl.

Initial therapy consisted of intravenous magnesium sulfate and hydralazine. Shortly after admission, her blood pressure dropped to 70s/40s torr. Fetal heart rate baseline decreased to the 80s bpm. An emergency C-section was performed. A hemoperitoneum of approximately 2,000 milliliters was found. A 682-gram female was delivered with Apgars of 0, 2, and 2. The cord umbilical artery pH was 6.55. A 3 cm tear in the maternal liver capsule was discovered. The right lobe of the patient’s liver ruptured. Surgeons performed a Pringle maneuver to control the blood loss. Liver was packed and a Bogata closure with vacuum pack dressing was used. Patient’s hemoglobin was 5 g/dl and platelets were 4,000/mm3. Patient received 10 units of packed red blood cells, 914cc of platelets, 400cc of fresh frozen plasma, 2 liters of crystalloid, and 700cc of colloid. Patient was treated for oliguria, hypovolemic shock, and disseminated intravascular coagulation (DIC). When the left lobe of the liver ruptured later the same day, fibrin glue was applied to the liver and the area was repacked. Magnesium sulfate infusion was discontinued due to hypermagnesemia. It was necessary to apply fibrin glue, repack and revise the vacuum pack dressings on several occasions. After her 9th exploratory laparotomy, her wound incision was closed on post op day four. During this time, she received 24 units of packed red blood cells, 14 units of fresh frozen plasma, 30 units of platelets, 14 units of cryoprecipitate, and 4 ampules of recombinant factor VIIa. This patient was extubated on postoperative day seven and continued to progress well. We treated her hypertension with hydralazine and labetalol. On postoperative day nine, she complained of dizziness, headaches, and muscle weakness. The following day, she developed focal andNOVEMBER/DECEMBER 2005, VOL. 101 261

subsequently tonic-clonic generalized seizures. She was treated with phenytoin, lorazepam, and dexamethasone. Despite therapeutic phenytoin levels, she continued to have seizures. She eventually responded when magnesium sulfate therapy was reinstituted. Magnetic resonance images of the brain showed an acute infarct in the left hemisphere of the brain at the temporal-parietal junction. CT scans showed pronounced edema. With treatment, she improved rapidly, became seizure-free and there was resolution of cerebral edema. Magnesium sulfate was discontinued after one week. Her blood pressures normalized. Physical therapy was continued. She showed no residual signs of right-sided weakness and was discharged on postoperative day 24. The baby was discharged after 131 hospital days. She required a G-tube for supplemental feedings and she was diagnosed with retinopathy of prematurity and chronic lung disease.

DiscussionPreeclampsia (1) is a disease seen only in human pregnancy. Cardinal signs include elevated blood pressures, proteinuria, and nondependent edema. Symptoms are variable and may affect every organ system to varying degrees. Our patient had a rapidly evolving clinical picture and developed nearly every complication associated with preeclampsia: HELLP syndrome, subcapsular liver hematoma and rupture, DIC, eclampsia and cerebral edema. Pregnancy induced hypertension occurs in approximately 20%-25% of pregnancies (3), and is directly responsible for 18% of maternal deaths in the United States (4). In the general population, the incidence of preeclampsia is approximately

5%-8% (1). In the presence of pre-existing hypertension and underlying lupus, the incidence can be as high as 15%-20%. HELLP syndrome and subcapsular liver hematoma with rupture is associated with 30% maternal mortality (1-3, 5). The incidence of liver rupture is approximately 1:45,000 live births, whereas, the incidence of eclampsia is 1:2,000-3,000 pregnancies. Most cases of eclampsia develop within 24 hours of delivery, but they may occur up to 10 days postpartum. For future pregnancies, there is an approximately 2% risk of developing eclampsia (1,3). This patient’s preeclampsia was superimposed on her chronic hypertension and connective tissue disorder. These are known risk factors (1,3). Currently, there is no known cause for preeclampsia and no single screening test has been found to be reliable or diagnostic (1). Treatment of severe preeclampsia or HELLP syndrome prior to 23 and after 34 weeks gestation includes delivery (1,5). Between 24 and 34 weeks gestation, expectant management for a limited period of time has been advocated in some cases to allow for improved fetal growth and maturity. Treatment guidelines are fairly well established (1,5). One must balance the risks of delivering a premature infant vs. maintaining a pregnancy in the presence of severe preeclampsia with its associated risks of maternal and fetal morbidity and mortality. Patients with HELLP syndrome may benefit from blood product transfusion and plasmapharesis (1, 5). Magnesium sulfate remains the preferred method of prevention or treatment of eclampsia. Liver rupture in HELLP syndrome requires rapid and aggressive medical and surgical complex treatments. The

experience in our patient’s case confirms the need for such complex interventions. In addition to more accepted treatments for liver rupture in HELLP syndrome patients, the use of recombinant factor VIIa represents a relatively new adjunct therapy that appears to be beneficial in achieving hemostasis (2). Its use earlier in the clinical course of this disease might decrease the extent and frequency of complications due to hemorrhage.

ConclusionWe report a case of successful treatment of a patient with many and severe complications due to preeclampsia/eclampsia and HELLP syndrome. Multiple and complex treatment modalities, including the use of recombinant factor VIIa, were necessary to rescue mother and fetus and to achieve as optimal an outcome as possible.

Governor Manchin To Receive AMA’s Highest AwardDr. Faheem presented his remarks with WVSMA President Dr. Elizabeth Spangler. “As president of the WVSMA and chair of our Medical Foundation, it is certainly an honor to be part of this special announcement today,” said Dr. Spangler. “Our State Medical Association was established in 1867 with one of the main foundation goals to promote public health. To that end, the WVSMA established our West Virginia Medical Foundation which has taken an ongoing leadership role in bringing government, business, education, faith-based and non-profit organizations together in coalition, to tackle health issues in the state of West Virginia, in particular, the epidemic of obesity in the state. This initiative will compliment and support the work of the Office of Healthy Lifestyles established by Governor Manchin through his visionary leadership and dedication to improving the health of all West Virginians and the Healthy Lifestyles Coalition, which is chaired by First Lady Gayle Manchin.” Governor Manchin stated that he was truly humbled that the American Medical Association had selected him for this wonderful honor. “This national recognition is a great reflection upon the efforts we, working together, have instituted in our state to address the important health care issues that are impacting generations of West Virginians,” Governor Manchin said. “During my first regular legislative session as Governor, I was pleased to work with the members of the Legislature and the doctors and professionals of the West Virginia’s health care community on passage of the 2005 Healthy Lifestyles Act. I am pleased to report that we will be moving forward with the expansion of this Healthy Lifestyles effort into our schools during the coming months.” Governor Manchin will be presented his award by the officers of the AMA at a banquet in Washington, D.C. on March 14. He is the second West Virginian to be honored with the Dr. Nathan Davis Award; Senator Rockefeller received the award in 1991.

Governor Joe Manchin is applauded by WVSMA President Dr. Elizabeth Spangler, WVSMA Executive Director Evan Jenkins, Dr. Ahmed Faheem, a past president of the WVSMA who nominated him for the Dr. Nathan Davis Award, and the other guests attending the press conference.

Governor Joe Manchin has been selected as one of the eight recipients of the American Medical Association’s Dr. Nathan Davis Award for Outstanding Government Service. Dr. Ahmed Faheem of Beckley, a past president of the WVSMA, nominated Governor Manchin for this award, which is named for the founder of the AMA and recognizes significant achievements of federal, state and municipal elected officials who advance public health. The award was announced at a press conference in the Governor’s Office on January 18.

“Governor Manchin deserves this award because he demonstrated strong leadership in making West Virginia’s obesity crisis a top public policy priority and taking decisive action to address the crisis through his innovative Healthy Lifestyles Act,” said Dr. Faheem. “Governor Manchin has given new hope to the youngest West Virginians and has insured that the positive impact will be felt in the state for generations to come. I thank you on behalf of my four grandchildren and the children of the state of West Virginia.”

WVSMA leaders, Alliance members and staff joined with other members of the medical community to congratulate Governor Joe Manchin and First Lady Gayle Manchin.264 WEST VIRGINIA MEDICAL JOURNAL

Register Today for WVSMAA/WVSMA Spring Discovery Weekend, Foundation’s Healthy West Virginia SummitFinal details are being made for “A Spring Discovery Weekend,”a “family-friendly” event for physicians and their families at Glade Springs Hotel and Conference Resort in Daniels, April 28-30. This event is being co-sponsored by the WVSMA Alliance and the WVSMA. The weekend will kickoff on Friday evening at 6 p.m. with Family Fun Night, a variety of activities for all ages, and then a buffet dinner. After dinner, participants will be able to enjoy s’mores around the campfire if the weather permits, but if it doesn’t, an ice cream social will be offered. This special evening treat is being sponsored by the Southern Medical Association, Dr. Terry Elliott, councilor. On Saturday morning, a buffet breakfast will be available for participants from 7:15 a.m. - 9 a.m. The WVSMA Alliance will conduct its Annual Business Meeting and install their new officers from 8 a.m. - 10 a.m. During this time period, physicians may attend a Legislative Update from 8 a.m. - 9 a.m., and then a CME Session session on “Creating a Culture of Safety in Office Practice.”* This seminar will be presented by Judy Davis, director of risk for Acordia Professional Services on behalf of the WV Mutual Insurance Company. Following a break, the morning’s activities will continue with a session on “Identity Theft,” presented by WVSMAA Vice President Jo-Anne Bala, who was a victim of identity theft. After this session, Colleen Gardner, chair of the AMAA Health Promotion Committee, will discuss “Faux Paw — The Techno Cat,” an Internet safety program designed to keep children safe from online dangers. This program is promoted by the AMA Alliance. After a buffet luncheon, no events are planned on Saturday afternoon so physicians and their families can enjoy the many recreational facilities available at Glade Springs or go on an optional shopping trip to Tamarack. On Saturday evening, a reception and a Murder Mystery Dinner Theater presentation are planned. The weekend’s events will conclude on Sunday morning after the WVSMA Alliance Past Presidents’ Breakfast. Complete details about the Spring Discovery Weekend and a registration form are published in this issue beginning on the next page. In addition, you may also phone Nancy Hill at (304) 925-0342, ext. 20 or contact her at nancy@wvsma.com. Another important upcoming event that will be of special interest for for WVSMA physicians and Alliance members is the “Healthy West Virginia Summit,” which the West Virginia Medical Foundation is helping to host. This summit will convene stakeholders who are interested in establishing a culture that promotes a healthy lifestyle including healthy food choices and increased physical activity. The purpose of the Summit is to increase West Virginians’ knowledge of strategies and interventions that promote good health and to challenge them to take action in their local communities. In addition to plenary sessions that will include national keynote speakers, the Summit will have tracks for the following target audiences: ? Business Leaders and Policymakers ? Healthcare Professionals ? Grassroots Community and Faith-based Leaders ? Educators Check the HealthyWV.com website for Summit updates. For more information, contact Anne Roberts at Anne@wvsma.com or at (304) 925-0342, ext. 24.

*This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of CAMC Health Education and Research Institute and the West Virginia State Medical Association. The CAMC Health Education and Research Institute is accredited by the ACCME to provide continuing medical education for physicians. The CAMC Health Education and Research Institute designates this CME activity for a maximum of 1 hour in category 1 credits toward the AMA Physician’s Recognition Award.

THE WEST VIRGINIA STATE MEDICAL ASSOCIATION ALLIANCE and THE WEST VIRGINIA STATE MEDICAL ASSOCIATION PROUDLY PRESENT

A Spring Discovery WeekendApril 28-30, 2006Join us at the superb Glade Springs Resort in Daniels, West Virginia and find out how much we have to offer you! Come and discover: A Family Friendly Weekend and enjoya Family Fun Night

Come and discover: How to “Create a Culture of Safety inthe Office Practice”*

Come and discover: How to protect yourself from identity theft Come and discover: “Faux Paw” - an Internet safetyprogram for parents and children

Come and discover: Whodunit??? Put your detectiveskills to the test at a Murder Mystery Dinner

Spring Discovery Weekend Schedule of EventsFriday, April 286 PM 7:30 PM 9 PM Family Fun Night Dinner S’mores around the campfire, weather permitting, or an ice cream social will be held. This special evening treat is being sponsored by Southern Medical Association, Dr. Terry Elliott, Councilor.

*This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the CAMC Health Education and Research Institute and the West Virginia State Medical Association. The CAMC Health Education and Research Institute is accredited by the ACCME to provide continuing medical education for physicians. The CAMC Health Education and Research Institute designates this CME activity for a maximum of 1.0 hours in Category I credits toward the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those credits that he/she actually spends in the activity.

Saturday, April 292 PM Optional shopping trip to Tamarack

OrYou may enjoy the afternoon at your leisure. Glade Springs Resort offers many activities. Some of the events and facilities include:

Babysitting will be offered, however, arrangements must be made in advance. For more information about the meeting, contact WVSMA Alliance Liaison Nancy Hill at (304) 925-0342, ext.20 or (800) 257-4747, ext.20 or nancy@wvsma.com

Name _______________________________ Name of spouse attending_______________________ Name(s) & ages of child(ren) attending ________________________________________________ Address___________________________________________________________________________ City/State/Zip_____________________________________Phone____________________________ Registration fee is $50 per person, $100 per couple and includes any CME credits offered; all meetings and seminars; Family Fun Night and the Murder Mystery Dinner Theater. There is no registration fee for children. Total $ _______________Payment by: Check_________ VISA_________ Mastercard_________ American Express________ Card Number:_______________________________________ Customer Code: the last three digits found in the Signature block on reverse of card______________ Expiration date:_________________________________ Cancellation Policy: There will be a $25 administrative fee for cancellations after April 14. If paying by check, please send registration form and a check payable to the WVSMA to: West Virginia State Medical Association, P.O. Box 4106, Charleston, WV 25364 Phone: (304) 925-0342, ext.20 Toll free: (800) 257-4747, ext.20 Fax: (304) 925-0345

The registration fee does not include any lodging costs. A block of rooms has been reserved and reservations should be made as soon as possible. For reservations, please call the Glade Springs Resort at 1-800-634-5233. Room charges include meals for adults and children. Day only attendee meal rates are available. For more information, please contact WVSMA Alliance Liaison Nancy Hill at (304) 925-0342, ext.20 or (800) 257-4747, ext.20 or nancy@wvsma.com

A Call to Action to Fight the Obesity EpidemicJune 4-5, 2006 Embassy Suites, CharlestonFor details and registration please visit: www.healthywv.comJoin business, education, healthcare and faith-based leaders as well as policymakers to debate the issues and present solutions.

NOVEMBER/DECEMBER 2005, VOL. 101

271

Bureau for Public Health NewsGovernor Hosts Pandemic Flu SummitGovernor Joe Manchin III hosted a Pandemic Flu Summit on January 12 in Charleston, which was sponsored by Secretary Martha Walker of the West Virginia Dept. of Health and Human Resources (DHHR) and Secretary Jim Spears of the West Virginia Dept. of Military Affairs and Public Safety (DMAPS) and their agencies. The keynote speaker for the summit was U.S. Dept. of Health and Human Services (DHHS) Secretary Michael Leavitt, who announced West Virginia will receive $940,502 in the first round of funding from Congress for pandemic flu planning. About 400 invited guests attended the summit including personnel from local health and emergency management agencies, as well as business and community partners involved in pandemic flu planning in their towns and counties. Other speakers at this event were Dr. Catherine C. Slemp, executive director of the Division of Threat Preparedness, and Jimmy Gianatto, director of the Division of Homeland Security and Emergency Management, and leaders from the U.S. Dept. of Homeland Security and DHHS. The summit concluded with a town hall style meeting between the audience and panelists from the West Virginia Hospital Association, West Virginia Dept. of Education, WV Dept. of Agriculture, West Virginia Chamber of Commerce, DHHS, U.S. Dept. of Homeland Security and the U. S. Dept. of Agriculture. Some of the important messages presented during the summit were as follows:

3. There is currently no bird flu in the U.S.This virus may well show up in U.S. bird populations through migration. State and federal Departments of Agriculture are familiar with handling avian flu outbreaks in birds. Assuming the next pandemic flu virus emerges outside the U.S., there will likely be at least some warning. Advance warning can help us know who is most at risk and what they can do to protect themselves.

4. Pandemic influenza preparedness can significantly advance preparedness for all types of health disasters or other emergencies.Good groundwork has been laid to advance influenza pandemic preparedness. The federal government is working with vaccine manufacturers to find ways to produce flu vaccine more quickly and in this country. Domestic vaccine production capacity could help address recent problems with vaccine timeliness and supply. Flu remains our most common vaccine preventable disease in West Virginia.

5. No state or nation is fully prepared for an influenza pandemic.Health threat preparedness work undertaken by public health agencies and hospitals over the past few years has advanced our preparedness for pandemic flu. Increasingly across West Virginia, emergency response partners have built strong relationships and forged working partnerships.

1. Influenza pandemics happen.History has accounts of flu pandemics going back to at least the 1500s. They tend to occur several times a century (every 10-40 years). In the 20th Century, there were three pandemics. The most famous (and most severe) was the 1918 pandemic. Pandemics also occurred in 1957 and 1968. We are now overdue for a pandemic.

6. Pandemic influenza planning should take place within existing emergency planning channels.Local emergency management agencies are responsible for overseeing community emergency planning. County commissions are responsible for assuring this occurs. Regional Health Care System Planning Groups are in place across the state. Local health departments are working in regional partnerships across the state. It is important to work through these groups and to assure inclusion of broad partners, e.g., business, industry, education, transportation, etc. Planning needs to be aimed at sustainable approaches.

2. Avian flu is now causing disease in birds and occasionally in people.While this virus could evolve to cause the next pandemic, it is by no means certain that this will occur. Other viruses could also arise to cause the next pandemic. To date, human illness caused by bird flu has been from close contact with sick birds. The illness seen is clinically more severe than illness from annual flu. As of January, the virus has not developed the ability to readily spread person to person.

272 WEST VIRGINIA MEDICAL JOURNAL

7. Pandemic preparedness should be built upon strong, well established core emergency response systems, including emergency management entities, local health departments, etc.Decisions around community control measures and prioritization of limited resources (vaccines, antivirals, medical supplies, etc.) are difficult. They deserve public discussion in advance. While useful tools, antivirals and vaccines are not “magic bullets.” The public should be engaged to establish realistic expectations and provide input. The public needs to know in advance what they can do to protect themselves — during both annual flu outbreaks and during pandemics. In a moderately severe pandemic, HHS estimates that absenteeism due to illness, caring for an ill family member, or fear of coming to work could be as high as 40% in the peak weeks of a pandemic. Absenteeism can significantly disrupt community infrastructure and the economy, e.g., business supply chains, governmental sectors, transportation, security, tourism, etc. Economic consequences of a pandemic may be severe.

8. Continuity of operations planning through all sectors is important.While no pandemic will be easy to weather, advance preparedness and planning can make a difference. Planning needs to include all levels of government and it should include a broad array of sectors - education, elected officials, business and industry, faith-based communities, health care partners, etc. DHHR and DMAPS are working with local health departments and emergency management agencies to conduct pandemic flu summits around the state. Check www.wvflu.org for updates on these summits, and information is also available at www.pandemicflu.org.

WVUH Certified As Primary Stoke CenterThe Joint Commission on Accreditation of Health Care Organizations (JCAHO) has certified WVU Hospitals as a Primary Stroke Center. The Commission’s Certificate of Distinction for Primary Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care. Achievement of certification signifies that the services the WVUH Stroke Center provides have the critical elements to achieve long-term success in improving outcomes. The Joint Commission’s Primary Stroke Center Certification Program is based on the Recommendations for Primary Stroke Centers published by the Brain Attack Coalition and American Stroke Association statements for stroke to evaluate hospitals functioning as primary stroke centers.

WVUH-East Expands Cancer ProgramWVUH-East President and Chief Executive Officer Roger Eitelman has announced plans to expand the system’s cancer program based at City Hospital in Martinsburg. Program expansion plans that are currently underway include an equipment upgrade for the radiation therapy service in the McCormack Center to offer additional therapy, a new outpatient cancer treatment center on the second floor at City Hospital and enhancements to City Hospital’s dedicated inpatient oncology unit. The first step in the process of upgrading the WVUH-East cancer program occurred on Feb. 1 when Timothy K. Bowers, M.D., was named274 WEST VIRGINIA MEDICAL JOURNAL

medical director. A board-certified oncologist/hematologist/internist, Bowers has been practicing in Martinsburg since January 1979. He is a graduate of the WVU School of Medicine and completed his internship and residency at the University of Minnesota in Minneapolis. Bowers will chair the cancer committee and work closely with two other board certified medical oncologists — Terrence Reidy, M.D., and Matthew “Page” Jones, M.D. -— medical staff and oncology nursing staff to develop short- and long-term goals for the program. He will also continue to see patients in his private oncology practice in Martinsburg. “It’s an honor to be named the medical director for the WVUH-East cancer program at City Hospital,” Bowers said. “I look forward to the opportunity to provide leadership and direction for the growth and development of the oncology services here in the Eastern Panhandle.” For many years, Bowers has chaired City Hospital’s cancer committee, which is responsible for the overall organization and supervision of the hospital’s cancer services. “The cancer committee is charged with assuring that the diagnosis and treatment of cancer patients is held to high-quality standards and that the entire spectrum of ancillary and support services is available to each patient as needs dictate,” Bowers said, adding that this will continue to be a focus for him as the medical director of the cancer program for WVUH-East.

a hematologist oncologist, specializing in umbilical cord blood transplantation, has joined the BMT/HM team and is currently developing a protocol for the alternative transplant option. Umbilical cord blood comes from the placenta, which is typically removed and thrown away after childbirth. An umbilical cord blood transplant involves the transfer of blood from the placenta to an individual whose own blood production system is suppressed by anticancer drugs, radiation therapy, or both. Cord blood contains high concentrations of stem cells needed to produce new blood cells. “Cord blood is a priceless commodity that can save lives,” Visweshwar said. “It is another option for patients who may require transplant treatment but have no sibling donor.” Only about 30 percent of Caucasians in need of a blood or marrow transplant have a sibling donor. Finding a matched unrelated donor can be difficult and too time-consuming for a patient whose health is deteriorating. Cord blood can be an attractive option. International cord blood databases provide a large donor pool and an acceptable cord blood unit can usually be acquired within a two-week period. “This will be a tremendous enhancement to WVU’s Cancer Center and the range of services we can offer,” said Solveig G. Ericson, M.D., Ph.D., director of the BMT/HM Program. “We have several patients who have no sibling donor and no suitable donor options in the pool of volunteer unrelated donors. They will benefit from this type of transplant.” Another advantage of cord blood transplantation is that patients are less likely to develop graft-versus-host disease - a major, life-threatening complication that results when the stem cells from the donor and patient do not closely match.

Edwards Comprehensive Cancer Center OpensThe Edwards Comprehensive Cancer Center opened for patients on Jan. 9, offering an extensive range of diagnostic and treatment tools, including a PET/CT scanner, digital mammography and full CT capabilities. “The center promises a heretofore unavailable broad spectrum of cancer care options, resulting in higher likelihood of successful treatment, a greater probability of cure, and absolutely the best opportunity for sustaining a normal quality of life subsequent to therapeutic intervention,” said Dr. Charles H. McKown Jr., dean of the School of Medicine and Marshall’s vice president for health sciences. The center’s medical staff includes medical, surgical and radiation oncologists, in addition to gynecologic, pediatric and surgical oncology specialists. It is equipped with the Discovery ST, a redesigned PET/CT system completely optimized for cancer care. The system provides a synergistic blend of the two technologies, using the PET scanner’s ability to identify areas showing the increased metabolic activity characteristic of malignancies and then using CT scanning to pinpoint the location of the lesions. “In cancer care, the Discovery ST allows you to not only see the disease, but to begin to treat it,” said Dr. Peter Chirico, assistant professor of radiology and director of radiology at Cabell Huntington Hospital. “The larger bore size (70 cm) and shorter tunnel length (100 cm) offer more flexibility in positioning larger patients, allow better radiation therapy planning, and help claustrophobic patients. The system also offers respiratory gating, a new technique that allows more accurate treatment of targets that move due to breathing.”276 WEST VIRGINIA MEDICAL JOURNAL

The fused PET and CT scans produced by the Discovery ST system provide excellent sensitivity and specificity, providing clinical confidence for diagnosis and treatment.

In addition to excellent sensitivity and specificity, the system gives physicians the ability to monitor the effectiveness of treatment and make mid-course corrections. PET/CT fusion imaging is useful for lung, esophageal and metastatic colorectal carcinoma, the evaluation of pulmonary nodules, the lymphomas, breast cancer, and head and neck malignancies. In addition to the PET/CT system, the center features state-of-the-art radiation therapy technology, including image guided radiation therapy. It also is equipped to provide high dose rate brachytherapy. Primarily used in treating breast, prostate and gynecological cancers, brachytherapy can now be used in areas such as the lung, head and neck, thanks to more precise targeting methods. “The center ... contains almost every diagnostic and treatment tool

OFFICE MANAGERS ASSOCIATION OF HEALTHCARE PROVIDERS, INC.www.officemanagersassociation.comWe invite you to join our organization which consists of members who manage the daily business of healthcare providers. Our objectives are to promote educational opportunities, professional knowledge and to provide channels of communication to office managers in all areas of healthcare. We currently have eleven chapters in West Virginia.

Visit us on our website for more information or contactDonna Zahn (President) at 740-283-4770 ext. 105 or Tammy Mitchell (Membership) at 304-324-2703.

West Virginia School of West Virginia School of Osteopathic Medicine Osteopathic MedicineN e w sCollege Park, Md. He has served in the U.S. Army as platoon leader and asst. secretary of the general staff in Kaiserslautern, Germany, and as Commander of Alpha Company, 16th Ordinance Battalion at Aberdeen, Md. Currently, he is commissioned as a U.S. Army Reserve officer. the public school system for 31 years, including positions as teacher, counselor, assistant principal, principal, and director of personnel for Greenbrier County Schools. Curry currently serves as superintendent of Greenbrier County Schools. Rowe is a former chairman of the BOG. Rowe, an alumna of WVU, previously served on the staff of U.S. Senator Jacob K. Javits. She is vice president of communications for The Greenbrier in White Sulphur Springs. Three new representatives were recently elected by their peers to serve on the WVSOM BOG. Those individuals are: George Boxwell, D.O. (faculty representative); Barbara Bragg (classified representative); and Ben Palmer (student body representative). Dr. Boxwell is a graduate of Olivet College in Olivet, Mich. He earned his doctor of osteopathy degree from Kirksville College of Osteopathic Medicine in Kirksville, Mo. Boxwell is the former director of medical education at the Robert C. Byrd Clinic, and former chairman of the WVSOM Clinical Sciences Division. He is a tenured professor in family medicine with 17 years of service at WVSOM. Boxwell also maintains a family medicine practice at the Robert C. Byrd Clinic and Greenbrier Valley Medical Center. Barbara Bragg has an associate of science degree in general business and a bachelor of science degree in accounting from Bluefield State College. She will earn her M.B.A. from WVU in December 2005. Bragg has been employed at WVSOM for 16 years and now serves as business manager in the Office of Business Affairs. Second-year medical student Ben Palmer is a native of Kingsport, Tenn. He graduated from the U.S. Military Academy at West Point, N.Y. with a bachelor of science degree in Environmental Science. Palmer later earned a master of science degree in Management Information Systems from the University of Maryland in○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Eight New Members Appointed to WVSOM Board of GovernorsEight newly appointed individuals have been selected to serve on the West Virginia School of Osteopathic Medicine’s Board of Governors, according to WVSOM President Olen E. Jones, Jr., Ph.D. Five new lay members have been appointed to the WVSOM BOG: Kendall Wilson, D.O.; Paul Kleman, D.O.; John Curry, M.S.; Donald Newell, Jr., D.O.; and Sharon Rowe. They were approved by Governor Joe Manchin to serve four-year terms. Dr. Wilson is an associate clinical professor at WVSOM who has a private practice in Lewisburg. He received a bachelor of science degree in biology from Randolph-Macon College in Ashland, Va., and a master of science degree in pathology from the Medical College of Virginia in Richmond. He is a 1981 graduate of WVSOM. Dr. Kleman holds the title professor emeritis at WVSOM and he is the school’s former director of medical education and associate dean for clinical training. He previously served on the WVSOM BOG from 1990-91 as a faculty representative. Dr. Kleman earned his pre-medical degree from the University of Arizona in Tucson, Ariz., and graduated from the Kansas City College of Osteopathic Medicine in Kansas City, Mo. Dr. Newell is a former chairman of the BOG. He earned a bachelor of science degree in biology from Bethany College in Bethany, W.Va., and a doctor of osteopathy degree from Kirksville (Missouri) College of Osteopathic Medicine. Newell owns and operates the Fayette Clinic, a rural family medicine practice in Lochgelly, W.Va. Curry is a graduate of Pikeville College and the WVU College of Graduate Studies. He has worked in278 WEST VIRGINIA MEDICAL JOURNAL

Students Report Areas Ravaged by Hurricane Still in Dire NeedWVSOM medical students Chris Heddon, Kristina Janssen and Sarah Dempsey recently traveled to Long Beach, Miss., to assist with the Hurricane Katrina relief effort. “There aren’t words to describe what we saw. It looked like a war zone, everywhere we turned,” said Dempsey, who spearheaded the effort to assist in the relief effort. “We drove for miles and miles, and every direction we looked, we only saw destruction: trucks in pools, boats in the middle of roads, a child’s swing set in a mound of rubble. It was hard to believe that four months had passed since Hurricane Katrina hit. With the debris, the destruction, the trash still in the trees, one would think that the hurricane hit a few days ago.” The students say the need for food, clothing and volunteers is still critical to the rebuilding effort. To survive, many families must rely exclusively on donations. But the available goods depend on shipments that come in on trucks daily from around the country. “Some days there is an abundance of food, sometimes there isn’t. Items like toilet paper and any new clothes were limited to one per person,” Dempsey explained. The students would like to thank everyone who helped with the charity golf tournament this past October, which provided funds for their trip and the relief effort.

The WVSMA would like to thank the following physicians, residents, medical students and Alliance members for their contributions to WESPAC for 2005 and 2006:

ObituariesCarl R. Adkins, M.D.Carl R. Adkins, M.D., 61, formally of Fayetteville, died February 2, in Aiken, S.C. Dr. Adkins was a past president of the WVSMA, who served from 1983-84. Dr. Adkins was born July 16, 1944, in Holden, son of the late Carl L. Adkins and Louise Adkins. He earned an undergraduate degree from West Virginia University in 1965, and then was one of the members of the first graduating class of the WVU School of Medicine in 1972. He interned at Roanoke (Virginia) Memorial Hospital and received an M.B.A. from Wake Forest University. For 11 years, Dr. Adkins served as a family practitioner in Fayetteville, during which time he was president of the Fayette County Medical Society, an elder of the Fayetteville Presbyterian Church and was a member of the Rotary chapter. When Dr. Adkins served as president of the WVSMA from 1983-84, he was serving as director of emergency services at Raleigh General Hospital in Beckley and was president of Physician to Physician Associates, a medical management consulting firm. His business and consulting skills were applauded by Dr. Stephen Ward in an editorial which appeared in the West Virginia Medical Journal in August 1984. “He was just what the doctor ordered. Belying the old saw that doctors are always rotten businessmen, Carl R. Adkins finishes this month his term as president of the West Virginia State Medical Association and will turn over to his successor, Carl J. Roncaglione, M.D., an organization with a good balance sheet and one geared to function smoothly in the foreseeable future. . . . “The West Virginia State Medical Association enjoyed his consulting skills as a fringe benefit of his term as president. It is not just coincidence that a building program proposed and endorsed several administrations back finally reached fruition this spring with the start of construction of the State Medical Association office building.”284 WEST VIRGINIA MEDICAL JOURNAL

In addition to his dedication to the WVSMA, Dr. Adkins was a member of the AMA, the Board of Directors of the West Virginia Medical Institute, and the West Virginia Academy of Family Practice. He was a director of Fayettevile Federal Savings and Loan Association and he was also a Federal Aviation Administration flight examiner Dr. Adkins and his wife, Susan Hanlin Adkins, retired to Aiken, S.C. in 1998. In addition to his wife, Dr. Adkins is survived by a son, Jonathan Adkins of Arlington, Va.; and a sister, Frances Povlich. The family held a memorial service on Feb. 11 in South Carolina, and contributions be made to the Dr. Carl R. Adkins Fund, in care of WVU Foundation, P.O. Box 1650, Morgantown, WV 26507.

Carrel Mayo Caudill, M.D.Dr. Carrel Mayo Caudill, M.D., died peacefully in his sleep at Longboat Key, Fla., on January 1. “Doc,” as he was known to his friends and colleagues, was born in Pearisburg, Va., on Sept. 2, 1921. He was valedictorian of Pearisburg High School and earned both his undergraduate and medical degree from Duke University. He completed a rotating internship at Maryland General Hospital and a surgical internship at Duke University. He also spent two years as an Army Medical Officer at the VA Hospital in Roanoke, Va. He completed his neurosurgical residency at the University of Minnesota Hospital. Doc was a board-certified neurosurgeon who spent his entire 32-year career in practice in Charleston. He was a founding partner of Neurological Associates. His professional career was characterized by a dedication to providing the highest quality compassionate care to the people of southern West Virginia. He was instrumental in the hospital merger that led to the formation of Charleston Area Medical Center, where he served a term as chief of

staff. He also served as a clinical professor of Surgery at WVUCharleston Division. He was also a member of the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and many regional, state, and local medical societies. His family and his neurosurgical practice were Doc’s two greatest loves. He married Anne Campbell on March 25, 1944, and remained happily married for nearly 62 years. Together, they raised four children. Doc was an avid reader and worker of crossword puzzles, an expert in fine wines, and a baseball trivia aficionado. However, he will be remembered best by hospital co-workers for his ever-present pipe and Diet Coke. Doc was a dedicated member of Rotary International, and he was a long-time member of First Presbyterian Church of Charleston. After retiring in 1985, the Caudills moved to Longboat Key, Fla. Doc was preceded in death by his parents, Walter Cleveland Caudill, M.D., and Mary Cornett Caudill; and by an infant brother, Walter Cleveland Caudill Jr. In addition to his wife, Doc is survived by his daughters, Janet Caudill Cooksey and husband, Ben, of Colleyville, Texas, and Lucy Caudill Tucker, M.D., of Carrollton, Texas; sons, Franklin Terrell “Terry” Caudill and wife, Michela, of Baltimore, Md., James W. Caudill, M.D., and wife, Gloriann, of Charleston; seven grandchildren; and two greatgrandchildren. A private graveside service was held January 7 in Pearisburg, Va., and a memorial service was conducted on January 8 at First Presbyterian Church in Charleston. Memorial donations can be made to either CAMC Foundation or Union Mission Ministries.

Henry M. Hills Jr., M.D.Henry M. Hills Jr., M.D., died in the early hours on January 20. Dr. Hills was born on March 14, 1913 in Lamoni, Iowa, the son of

Henry and Kathryn Hills. He was the valedictorian of his high school class and then completed pre-med studies at Graceland College and the University of Iowa. He graduated from the University of Iowa Medical School in 1937 and received his surgical training at University Hospital in Iowa City, Iowa, and then came to Charleston for his residency in traumatic surgery in 1938. Dr. Hills practiced orthopedics with Dr. Randolph Anderson until an orthopedic residency position opened up at Massachusetts General Hospital in Boston. Dr. Hills began his residency, but then joined the Army when World War II started and he served with the 3rd Army 12th Evacuation Hospital for three years. Dr. Hills was awarded the Silver Star for his heroic actions involving entry into the city of Bastogen by glider to provide medical services to the American soldiers who were under siege by the German Army. After his military service, Dr. Hills completed his residency and then returned to Charleston in 1945 and resumed his orthopedics practice with Dr. Anderson until his retirement in 1998. Dr. Hills participated in clinics and provided charitable orthopedic services thoughout his entire professional career. In recognition of his life’s commitment to orthopedics, a commemorative plaque and portrait have been placed at the entry to the orthopedics wing of Charleston General Hospital. Dr. Hills is survived by his four children, Henry III, William, Sandra and Robert. Dr. Hills’ children are comforted by his welcome return to his departed wife and their mother, Margaret Logan Hills. They invite friends of Dr. Hills to make contributions to Kanawha Hospice Care, Inc., without whom their father’s passing might have been decidedly more difficult to bear.

K. Venkata Raman, M.D.Dr. K. Venkata Raman, a retired vascular surgeon who lead local relief efforts for the victims of the December 2004 tsunami, died January 16 of cancer. Raman was 66. A Huntington resident for 30 years, Raman was a native of Chennai, India, where 200 people died when the rushing walls of water hit southern Asia and eastern Africa. Dr. Raman made a yearly visit to India to see his mother and he put $25,000 toward purchasing medical supplies, fishing boats and nets to help the local people. Fisherman used the money to buy 15 new boasts and repair between 50 and 60 others. They were so grateful that they painted the name of Huntington across the side of one boat as a special tribute.

About $4,000 of the money that Dr. Raman contributed was raised by students at Fairland High School having a concert and yard sale, and by the younger students giving their change, said Jayshree Shah, a biology and physiology teacher. Shah said Dr. Raman had a positive outlook on life and was a caring person away from the hospital. She noted that shortly before his death, Dr. Raman told friends, “death was gracious,” and that he was ready. She also said that the day prior to his death, Raman insisted on continuing with a party to celebrate his son’s engagement. Raman is survived by his wife, Shanti, a son, Surat, and daughter, Anooradha. Raman’s family has requested memorial contributions be directed to the American Cancer Society or the Center for Meditation, 1129 11th Ave., Huntington, WV 25701.

Poetry CornerLetter to an RNYes, you are out to prove something. Indeed, you are good for people. To guide, nurture, comfort, care for — you earned the lamp you hold for us. Solace for the broken spirit not to stop believing — take hold never to abandon a charge. Inside-out, you’re a friend for life a penetration from your heart. You are a breed unto your own.John Henry McWhorter, M.D.

W I T H A S T R O K E , T I M E L O S T I S B R A I N L O S T.If you suddenly have or see any of these symptoms, call 9-1-1 immediately: Numbness or weakness of the face, arm or leg, especially on one side of the body ? Confusion, trouble speaking or understanding ? Difficulty seeing in one or both eyes ? Trouble walking, dizziness, loss of balance or coordination ? Severe headache with no known cause

Learn more at StrokeAssociation.org or 1-888-4-STROKE.

?2004 American Heart Association Made possible in part by a generous grant from The Bugher Foundation.

UROLOGISTOHIO - An established two-man group is seeking a new associate to replace a partner lost to illness. The practice serves three area hospitals with a combined 900-bed capacity. Guaranteed base salary of $260,000, but your production bonus is calculated exactly the same as the current partners from day one. Partnership is offered in one year, with minimal buy-in of low office overhead only. This practice has its own lithotripsy venture with affordable share price and there is an area surgery center that you can invest in if you wish. Contact:

OB/GYNwww.sidneyoh.com www.wilsonhospital.com OHIO - Two family oriented, female Ob/Gyns are looking for an associate to compliment their growing hospital-based practice in Sidney. This practice has new offices, a new state-of-the-art Birth Center and a new Women’s Health Center. It is part of a wellestablished, multi-specialty group. Annual compensation includes an attractive base salary plus incentive opportunity and an excellent benefit package. No J1 opportunities. Contact:

COOPER CONSULTING Cleveland, Ohio West Virginia and OH areas: 216-321-9906Call to explore how this stepwise strategy may assist your practice.

BOARD CERTIFIED ORTHOPAEDIC SURGEONSNeeded for non-treatment disability evaluation centers throughout New York State Full-time and Part-Time Employment/ Malpractice Included New York Practice NOT required to perform exams For more information, please reply with CV to:

At Chapman Printing we do more than just printing. From forms and stationery to color printing, office supplies and furniture—as part of the Champion Industries network, we have many powerful resources available to serve you better. Call a Chapman Printing sales representative today. We’ll help you make a statement—and more.

The Chapman Printing Company, Inc.

Charleston 304-341-0676 Toll Free 1-800-824-6620

YOUR BUSINESS. YOUR PEOPLE. YOU’RE COVERED.

When it comes to building a strong economy, BrickStreet provides the right foundation.